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HEALTH CARE SERVICES: MANAGED CARE
Managed care describes a health care delivery system comprised of the following elements:
1. A budget based on an estimate of the annual cost of delivering health care for a given population
2. A network of physicians, hospitals, and other providers and facilities linked contractually to deliver comprehensive health benefits within that predetermined budget, sharing economic risk for any budget deficit or surplus
3. An established set of administrative rules requiring patients to follow the advice of the participating health care providers in order to have their health care paid for under the terms of the health plan
Many such plans pay their contracted health care providers through capitation, that is, prepayment of a fixed monthly amount for each patient without regard of the type or number of health services provided. Some plans pay health care providers salaries and some are still fee-for-service plans. Much as with other insurance plans, enrollees are members of a risk pool, and it is expected that some persons will use no services, some will use a modest amount of services, and others will have high-cost utilization over a given year. Doctors have the incentive to keep their patient pool healthy and avoid the catastrophic ailments that are preventable; usually such incentives come back in terms of increased salaries, bonuses, and other benefits. As such, prevention and health education to reduce risk completely or intervene early and avoid major problems should be capstone components of such plans.
Managed care plans have grown steadily over the past decade with a proportionate decline of enrollment in traditional indemnity insurance plans. The reason for this shift is that indemnity insurance, which pays providers and hospitals on a fee-for-service basis with no built-in incentives to control health care costs, has become unaffordable for most Americans.
Today, managed care plans are sweeping the nation, with over 60 million Americans enrolled in one type of plan, the Health Maintenance Organization, and another 90 million in other types of managed care. Four million beneficiaries are in Medicare HMOs, with enrollment growing by about 80,000 people a month.
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GENERAL HEALTH
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